Acta Neurochir DOI 10.1007/s00701-013-1972-x
CLINICAL ARTICLE - NEUROSURGICAL TECHNIQUES
The anterior interhemispheric approach - a safe and effective approach to anterior skull base lesions Dorothee Mielke & Lothar Mayfrank & Marios Nikos Psychogios & Veit Rohde
Received: 30 September 2013 / Accepted: 4 December 2013 # Springer-Verlag Wien 2014
Abstract Background Many approaches to the anterior skull base have been reported. Frequently used are the pterional, the unilateral or bilateral frontobasal, the supraorbital and the frontolateral approach. Recently, endoscopic transnasal approaches have become more popular. The benefits of each approach has to be weighted against its complications and limitations. The aim of this study was to investigate if the anterior interhemispheric approach (AIA) could be a safe and effective alternative approach to tumorous and non-tumorous lesions of the anterior skull base. Methods We screened the operative records of all patients with an anterior skull base lesion undergoing transcranial surgery. We have used the AIA in 61 patients. These were exclusively patients with either olfactory groove meningioma (OGM) (n =43), ethmoidal dural arteriovenous fistula (dAVF) ( n =6) or frontobasal fractures of the anterior midline with cerebrospinal fluid (CSF) leakage ( n =12). Patient records were evaluated Presentation at a conference: German Association of Neurological Surgeons – Annual Meeting 2013; Düsseldorf, Germany Clinical Trial Registration: not applicable D. Mielke : V. Rohde Department of Neurosurgery, Georg-August-University Göttingen, Robert-Koch-Strasse 40, 37075 Göttingen, Germany L. Mayfrank : V. Rohde Department of Neurosurgery, University of Technology (RWTH) Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany M. N. Psychogios Department of Neuroradiology, Georg-August-University Göttingen, Robert-Koch-Strasse 40, 37075 Göttingen, Germany L. Mayfrank Neuro Clinic Stuttgart, Eierstrasse 46, 70199 Stuttgart, Germany D. Mielke (*) Neurochirurgische Klinik, Georg-August-Universität Göttingen, Robert-Koch-Strasse 40, D-37075 Göttingen, Germany e-mail: [email protected]
concerning accessibility of the lesion, realization of surgical aims (complete tumor removal, dAVF obliteration, closure of the dural tear), and approach related complications. Results The use of the AIA exclusively in OGMs, ethmoidal dAVFs and midline frontobasal fractures indicated that we considered lateralized frontobasal lesions not suitable to be treated successfully. If restricted to these three pathologies, the AIA is highly effective and safe. The surgical aim (complete tumor removal, complete dAVF occlusion, no rhinorrhea) was achieved in all patients. The complication rate was 11.5 % (wound infection (n =2; 3.2 %), contusion of the genu of the corpus callosum, subdural hygroma, epileptic seizure, anosmia and asymptomatic bleed into the tumor cavity (n =1 each). Only the contusion of the corpus callosum was directly related to the approach (1.6 %). Olfaction, if present before surgery, was preserved in all patients, except one (1.6 %). Conclusions The AIA is an effective and a safe approach to tumorous, vascular and traumatic pathologies of the midline anterior skull base. This approach should be part of the armamentarium of skull base surgeons. Keywords anterior skull base . olfactory groove meningioma, dural arteriovenous fistula . skull base fracture . CSF fistula . interhemispheric approach
Introduction The anterior skull base extends anteroposteriorly from the crista galli to the tuberculum sellae and bilaterally from the midline to the sphenoid wing. This region harbors delicate neurovascular structures such as the optic and olfactory nerves and the anterior cerebral arteries. During the last decades, different approaches have been proposed to reach lesions that are located at the anterior skullbase. Frequently used are the unilateral or bilateral subfrontal approach [3, 6, 12, 35], the supraorbital [36], the pterional [14, 38, 39] as well as the
Acta Neurochir
frontolateral [9, 29, 32] approach. A trans-frontal-sinus approach has been proposed by some [4]. Besides, endoscopic transnasal approaches have gained more attention during the last years [5, 8, 10, 11, 17–20, 23, 28, 42] (Figs. 1, 2 and 3). The anterior interhemispheric approach (AIA) to the anterior skull base has sporadically been reported during the last years [7, 14, 21, 26, 27, 37], but the evaluation of its advantages and disadvantages in larger surgical series dealing with the treatment of different pathologies is lacking [14] and not limited to lesions of the anterior skull base, but rather including different types of suprasellar pathologies like craniopharyngeomas, thalamus gliomas and hamartomas or anterior communicating artery aneurysms. Thus, the aim of the present study was to evaluate the feasibility of the anterior interhemispheric approach to reach tumorous as well as vascular and traumatic anterior skull base lesions.
Methods and material Study design and data collection We retrospectively screened the medical records of patients with anterior skull base lesions (tumor, dural arteriovenous fistula [dAVF], trauma) undergoing transcranial surgery between 1990 and 2013 and searched for those cases, in which Fig. 1 a Contrast enhanced T1 weighted magnetic resonance image (MRI) of a large olfactory groove menigeoma. b, c Postoperative T2 weighted and contrast enhanced T1 weighted images depict complete surgical removal. d Volume rendering technique (VRT) reconstructions of the postoperative CT demonstrate the relatively small craniotomy after the anterior interhemispheric approach (AIA)
the AIA was used. In these cases, we reviewed preoperative and postoperative clinical findings, preoperative and postoperative diagnostic imaging and surgery-associated complications. Interestingly, the AIA was exclusively used in olfactory groove meningioma (OGM), ethmoidal dAVF and midline frontobasal fractures with dural laceration. Anterior interhemispheric approach (AIA) The technical details of the AIA have been described in detail before [26, 27]. Briefly, the patient is in a supine position, with the head slightly elevated and fixed in a Mayfield holder. After placing two burr holes on the superior sagittal sinus, a frontal bone flap between the coronary suture and the frontal sinus of about 4x4 cm is being cut to the right side. A U-shaped opening of the dura, pedunculated to the midline, is done. Since the mid-1990s, neuronavigation was used. Afterwards, the underlying pathology guides the next operative steps. In OGMs the superior dome of the tumor is being approached by dissecting along the falx and by minimal retraction of the frontal lobe (gap between medial aspect of the frontal lobe and the falx
CLINICAL ARTICLE - NEUROSURGICAL TECHNIQUES
The anterior interhemispheric approach - a safe and effective approach to anterior skull base lesions Dorothee Mielke & Lothar Mayfrank & Marios Nikos Psychogios & Veit Rohde
Received: 30 September 2013 / Accepted: 4 December 2013 # Springer-Verlag Wien 2014
Abstract Background Many approaches to the anterior skull base have been reported. Frequently used are the pterional, the unilateral or bilateral frontobasal, the supraorbital and the frontolateral approach. Recently, endoscopic transnasal approaches have become more popular. The benefits of each approach has to be weighted against its complications and limitations. The aim of this study was to investigate if the anterior interhemispheric approach (AIA) could be a safe and effective alternative approach to tumorous and non-tumorous lesions of the anterior skull base. Methods We screened the operative records of all patients with an anterior skull base lesion undergoing transcranial surgery. We have used the AIA in 61 patients. These were exclusively patients with either olfactory groove meningioma (OGM) (n =43), ethmoidal dural arteriovenous fistula (dAVF) ( n =6) or frontobasal fractures of the anterior midline with cerebrospinal fluid (CSF) leakage ( n =12). Patient records were evaluated Presentation at a conference: German Association of Neurological Surgeons – Annual Meeting 2013; Düsseldorf, Germany Clinical Trial Registration: not applicable D. Mielke : V. Rohde Department of Neurosurgery, Georg-August-University Göttingen, Robert-Koch-Strasse 40, 37075 Göttingen, Germany L. Mayfrank : V. Rohde Department of Neurosurgery, University of Technology (RWTH) Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany M. N. Psychogios Department of Neuroradiology, Georg-August-University Göttingen, Robert-Koch-Strasse 40, 37075 Göttingen, Germany L. Mayfrank Neuro Clinic Stuttgart, Eierstrasse 46, 70199 Stuttgart, Germany D. Mielke (*) Neurochirurgische Klinik, Georg-August-Universität Göttingen, Robert-Koch-Strasse 40, D-37075 Göttingen, Germany e-mail: [email protected]
concerning accessibility of the lesion, realization of surgical aims (complete tumor removal, dAVF obliteration, closure of the dural tear), and approach related complications. Results The use of the AIA exclusively in OGMs, ethmoidal dAVFs and midline frontobasal fractures indicated that we considered lateralized frontobasal lesions not suitable to be treated successfully. If restricted to these three pathologies, the AIA is highly effective and safe. The surgical aim (complete tumor removal, complete dAVF occlusion, no rhinorrhea) was achieved in all patients. The complication rate was 11.5 % (wound infection (n =2; 3.2 %), contusion of the genu of the corpus callosum, subdural hygroma, epileptic seizure, anosmia and asymptomatic bleed into the tumor cavity (n =1 each). Only the contusion of the corpus callosum was directly related to the approach (1.6 %). Olfaction, if present before surgery, was preserved in all patients, except one (1.6 %). Conclusions The AIA is an effective and a safe approach to tumorous, vascular and traumatic pathologies of the midline anterior skull base. This approach should be part of the armamentarium of skull base surgeons. Keywords anterior skull base . olfactory groove meningioma, dural arteriovenous fistula . skull base fracture . CSF fistula . interhemispheric approach
Introduction The anterior skull base extends anteroposteriorly from the crista galli to the tuberculum sellae and bilaterally from the midline to the sphenoid wing. This region harbors delicate neurovascular structures such as the optic and olfactory nerves and the anterior cerebral arteries. During the last decades, different approaches have been proposed to reach lesions that are located at the anterior skullbase. Frequently used are the unilateral or bilateral subfrontal approach [3, 6, 12, 35], the supraorbital [36], the pterional [14, 38, 39] as well as the
Acta Neurochir
frontolateral [9, 29, 32] approach. A trans-frontal-sinus approach has been proposed by some [4]. Besides, endoscopic transnasal approaches have gained more attention during the last years [5, 8, 10, 11, 17–20, 23, 28, 42] (Figs. 1, 2 and 3). The anterior interhemispheric approach (AIA) to the anterior skull base has sporadically been reported during the last years [7, 14, 21, 26, 27, 37], but the evaluation of its advantages and disadvantages in larger surgical series dealing with the treatment of different pathologies is lacking [14] and not limited to lesions of the anterior skull base, but rather including different types of suprasellar pathologies like craniopharyngeomas, thalamus gliomas and hamartomas or anterior communicating artery aneurysms. Thus, the aim of the present study was to evaluate the feasibility of the anterior interhemispheric approach to reach tumorous as well as vascular and traumatic anterior skull base lesions.
Methods and material Study design and data collection We retrospectively screened the medical records of patients with anterior skull base lesions (tumor, dural arteriovenous fistula [dAVF], trauma) undergoing transcranial surgery between 1990 and 2013 and searched for those cases, in which Fig. 1 a Contrast enhanced T1 weighted magnetic resonance image (MRI) of a large olfactory groove menigeoma. b, c Postoperative T2 weighted and contrast enhanced T1 weighted images depict complete surgical removal. d Volume rendering technique (VRT) reconstructions of the postoperative CT demonstrate the relatively small craniotomy after the anterior interhemispheric approach (AIA)
the AIA was used. In these cases, we reviewed preoperative and postoperative clinical findings, preoperative and postoperative diagnostic imaging and surgery-associated complications. Interestingly, the AIA was exclusively used in olfactory groove meningioma (OGM), ethmoidal dAVF and midline frontobasal fractures with dural laceration. Anterior interhemispheric approach (AIA) The technical details of the AIA have been described in detail before [26, 27]. Briefly, the patient is in a supine position, with the head slightly elevated and fixed in a Mayfield holder. After placing two burr holes on the superior sagittal sinus, a frontal bone flap between the coronary suture and the frontal sinus of about 4x4 cm is being cut to the right side. A U-shaped opening of the dura, pedunculated to the midline, is done. Since the mid-1990s, neuronavigation was used. Afterwards, the underlying pathology guides the next operative steps. In OGMs the superior dome of the tumor is being approached by dissecting along the falx and by minimal retraction of the frontal lobe (gap between medial aspect of the frontal lobe and the falx
